A 36-year-old man presents to the physician with difficulty in breathing for 3 hours. There is no history of chest pain, cough or palpitation. He is a chronic smoker and underwent elective cholecystectomy one month back. There is no history of chronic or recurrent cough, wheezing or breathlessness. His temperature is 38.2°C (100.8°F), pulse is 108/min, blood pressure is 124/80 mm Hg, and respirations are 25/min. His arterial oxygen saturation is 98% in room air as shown by pulse oximetry. After a detailed physical examination, the physician orders a plasma D-dimer level, which was elevated. A contrast-enhanced computed tomography (CT) of the chest shows a filling defect in a segmental pulmonary artery on the left side. Which of the following signs is most likely to have been observed by the physician during the physical examination of this patient’s chest?

Systolic murmur at the left sternal border

A 74-year-old woman is brought by ambulance to the emergency department and presents with a complaint of excruciating chest pain that started about 45 minutes ago. The patient was sitting in the garden when she 1st noticed the pain in the upper abdomen. The pain has persisted and now localizes underneath of the sternum and the left shoulder. Milk of magnesia and aspirin were tried with no relief. The patient had previous episodes of chest pain that were of lesser intensity and rarely lasted more than 10 minutes. She is diabetic and has been managed for hypertension and rheumatoid arthritis in the past. On examination, the patient is breathless and sweating profusely. The vital signs include blood pressure 140/90 mm Hg and heart rate 118/min. The electrocardiogram (ECG) shows Q waves in leads V2 and V3 and raised ST segments in leads V2, V3, V4, and V5. Laboratory studies (including cardiac enzymes at 6 hours after admission show: Hematocrit 45% Troponin T 1.5 ng/mL Troponin I 0.28 ng/mL Creatine kinase (CK)-MB 0.25 ng/mL The patient is admitted and started on analgesia and reperfusion therapy. She shows initial signs of recovery until the 6th day of hospitalization when she starts vomiting and complaining of dizziness. Physical examination findings at this time included heart rate 110/min, temperature 37.7°C (99.9°F), blood pressure 90/60 mm Hg. Jugular venous pressure is 8 cm. A harsh pansystolic murmur is present at the left lower sternal border. ECG shows sinus tachycardia and ST-segment elevation with terminal negative T waves. Laboratory studies show: Hematocrit 38% Troponin T 1.15ng/mL Troponin I 0.18 ng/mL CK-MB 0.10 ng/mL Which of the following best explains the patient's current clinical condition?

Acute ventricular septal rupture complicating myocardial infarction

Aortic dissection complicating myocardial infarction

A new myocardial infarction (re-infarction)

Acute pericarditis complicating myocardial infarction

Cardiac tamponade complicating myocardial infarction

A 55-year-old man presents to the emergency department for chest pain. He states that the pain started last night and has persisted until this morning. He describes the pain as in his chest and radiating into his back between his scapulae. The patient has a past medical history of alcohol abuse and cocaine abuse. He recently returned from vacation on a transatlantic flight. The patient has smoked 1 pack of cigarettes per day for the past 20 years. His temperature is 99.5°F (37.5°C), blood pressure is 167/118 mmHg, pulse is 120/min, and respirations are 22/min. Physical exam reveals tachycardia and clear air movement bilaterally on cardiopulmonary exam. Which of the following is also likely to be found in this patient?

Asymmetric blood pressures in the upper extremities

A 65-year-old man with hypertension and type 2 diabetes mellitus is brought to the emergency department 20 minutes after the onset of severe anterior chest pain and shortness of breath. He has smoked one pack of cigarettes daily for 30 years. He appears distressed. His pulse is 116/min, respirations are 22/min, and blood pressure is 156/88 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 98%. A grade 3/6, high-pitched, blowing, diastolic murmur is heard over the right upper sternal border. Which of the following is the most likely cause of this patient's symptoms?

Perforation of the esophageal wall

Obstruction of the pulmonary arteries

Fibrofatty plaque in the aortic wall

A 33-year-old man with a history of alcohol abuse and cirrhosis presents to the emergency department with profuse vomiting. The patient is aggressive, combative, emotionally labile, and has to be chemically restrained. The patient continues to vomit and blood is noted in the vomitus. His temperature is 99.2°F (37.3°C), blood pressure is 139/88 mmHg, pulse is 106/min, respirations are 17/min, and oxygen saturation is 100% on room air. The patient complains of sudden onset chest pain during his physical exam. A crunching and rasping sound is heard while auscultating the heart. Which of the following is the pathophysiology of the most likely diagnosis?

Inflammation of the pericardium

A 5-year-old girl is brought to the physician because of watery discharge from her right eye for 2 weeks. She and her parents, who are refugees from Sudan, arrived in Texas a month ago. Her immunization status is not known. She is at the 25th percentile for weight and the 50th percentile for height. Her temperature is 37.2°C (99°F), pulse is 90/min, and respirations are 18/min. Examination of the right eye shows matting of the eyelashes. Everting the right eyelid shows hyperemia, follicles, and papillae on the upper tarsal conjunctiva. Slit-lamp examination of the right eye shows follicles in the limbic region and the bulbar conjunctiva. There is corneal haziness with neovascularization at the 12 o'clock position. Examination of the left eye is unremarkable. Direct ophthalmoscopy of both eyes shows no abnormalities. Right pre-auricular lymphadenopathy is present. Which of the following is the most likely diagnosis in this patient?

Acute hemorrhagic conjunctivitis

A 64-year-old man presents to the emergency department with sudden onset of chest pain and an episode of vomiting. He also complains of ongoing nausea and heavy sweating (diaphoresis). He denies having experienced such symptoms before and is quite upset. Medical history is significant for hypertension and types 2 diabetes mellitus. He currently smokes and has smoked at least half a pack daily for the last 40 years. Vitals show a blood pressure of 80/50 mm Hg, pulse of 50/min, respirations of 20/min, temperature of 37.2°C (98.9°F), and oximetry is 99% before oxygen by facemask. Except for the patient being visibly distressed and diaphoretic, the examination is unremarkable. ECG findings are shown in the picture. Where is the most likely obstruction in this patient’s cardiac blood supply?

Left anterior descending artery

A previously healthy 49-year-old woman comes to the emergency department because of chest pain that radiates to her back. The pain started 45 minutes ago while she was having lunch. Over the past 3 months, she has frequently had the feeling of food, both liquid and solid, getting “stuck” in her chest while she is eating. The patient's vital signs are within normal limits. An ECG shows a normal sinus rhythm with no ST-segment abnormalities. An esophagogram is shown. Further evaluation is most likely to show which of the following?

Simultaneous multi-peak contractions on manometry

Gastroesophageal junction mass on endoscopy

Hypertensive contractions on manometry

Elevated lower esophageal sphincter pressure on manometry

Multiple mucosal erosions on endoscopy

A 32-year-old woman patient presents to her family physician with recurrent retrosternal chest pain. She has had similar episodes for the past 7 months along with difficulty swallowing solid as well as liquid food. She recently completed an 8-week course of a proton pump inhibitor, but she is still bothered by the feeling that food gets stuck down her 'food pipe'. Her pain is not related to exertion. She denies any history of acid reflux disease. Her blood pressure is 125/81 mm Hg, respirations are 21/min, pulse is 78/min, and temperature is 36.7°C (98.1°F). She currently does not have pain. A barium swallow X-ray image is normal. Which of the following tests would aid in the diagnosis of this patient's condition?

Additional therapy with proton pump inhibitors

Red flags in chest pain for USMLE Step 2 CK: High-Yield Diagnosis Lessons

Red Flags in Chest Pain - The Deadly Half-Dozen

📌 Mnemonic: PET MAC

Pulmonary Embolism: Acute-onset dyspnea & pleuritic chest pain. Look for tachycardia, hypoxia, signs of DVT.
Esophageal Rupture (Boerhaave's): Severe retrosternal pain after forceful vomiting. Palpable crepitus (Hamman's crunch).
Tamponade (Cardiac): Beck's triad (hypotension, JVD, muffled heart sounds). Pulsus paradoxus >10 mmHg.
Myocardial Infarction (ACS): Crushing substernal pressure, radiating to arm/jaw. Associated with diaphoresis, dyspnea.
Aortic Dissection: Sudden, severe tearing/ripping pain radiating to interscapular back. Asymmetric BPs (>20 mmHg difference).
Collapsed Lung (Tension Pneumothorax): Unilateral pleuritic pain, tracheal deviation away from affected side, absent breath sounds, hyperresonance.

⭐ A normal ECG does not rule out Acute Coronary Syndrome.

Cardiovascular Red Flags - Plumbing Problems

Acute Coronary Syndrome (ACS):
- Substernal chest pain or pressure ("crushing"), often radiating to the jaw, shoulders, or left arm; typically lasts >20 minutes.
- Not relieved by rest or sublingual nitroglycerin.
- Associated symptoms: diaphoresis, dyspnea, nausea, vomiting.
- Key diagnostics: Elevated Troponin levels, characteristic EKG changes.

Aortic Dissection:
- Sudden, severe "tearing" or "ripping" chest pain, radiating to the back (interscapular area).
- Asymmetric blood pressure (>20 mmHg difference between arms) or pulses.
- May present with a new diastolic murmur of aortic regurgitation or focal neurologic deficits.
⭐ Aortic dissection classically presents with a tearing chest pain radiating to the back, often with a significant blood pressure differential between arms (>20 mmHg).
Massive Pulmonary Embolism (PE):
- Presents with syncope, hypotension, and acute right heart failure.
- Classic triad (less common): pleuritic chest pain, dyspnea, and hemoptysis. Tachycardia and hypoxia are key signs.

Thoracic Red Flags - Pressure Cooker

Pulmonary Embolism (PE)
- Sudden-onset dyspnea, pleuritic chest pain, tachypnea, tachycardia.
- Virchow’s triad: stasis, hypercoagulability, endothelial injury.
- Use clinical probability scores to guide workup.

Tension Pneumothorax
- Sudden, severe unilateral chest pain and dyspnea.
- Signs: Tracheal deviation (away from affected side), hypotension, unilateral absent breath sounds, hyperresonance.
- Immediate needle decompression followed by chest tube.
Esophageal Rupture (Boerhaave Syndrome)
- Severe retrosternal chest pain after forceful vomiting/retching.
- 📌 Mackler's Triad: Vomiting, chest pain, subcutaneous emphysema.
- Hamman's sign: mediastinal crunching sound.
Cardiac Tamponade
- ⭐ > Beck's triad (hypotension, JVD, muffled heart sounds) is classic but only present in a minority of cases. Look for pulsus paradoxus (↓ in systolic BP >10 mmHg with inspiration).

High-Yield Points - ⚡ Biggest Takeaways

Tearing pain radiating to the back with a BP differential suggests aortic dissection.

Pleuritic pain, sudden dyspnea, and tachycardia point to pulmonary embolism.

Substernal pressure radiating to the arm or jaw with diaphoresis indicates acute coronary syndrome.

Tracheal deviation, hypotension, and JVD are critical signs of tension pneumothorax.

Severe pain after forceful vomiting suggests esophageal rupture (Boerhaave).

Beck's triad (hypotension, JVD, muffled heart sounds) signals cardiac tamponade.

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